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Effectuated enrollment in Georgia’s exchange stood at more than 396,000 people as of mid-2019. During the open enrollment period for 2020 health plans, 464,041 people signed up for private plans through the state’s exchange.

HHS estimated that 581,000 people in Georgia gained health insurance coverage from 2010 to 2015, as a result of the ACA. But Georgia hasn’t expanded Medicaid under the ACA, so the state has not taken full advantage of the ACA’s provisions. There are currently an estimated 267,000 people in the coverage gap in Georgia — ineligible for premium subsidies because they earn too little, and ineligible for Medicaid because the state has not accepted federal funding to expand coverage.

After several years of insurer exits and fairly substantial rate increases, Georgia’s individual insurance market appears to be stabilizing. The average rate increase for 2019 was less than 4 percent, and insurers have proposed an average rate increase of just 2.4 percent for 2020. And two new insurers — Oscar and CareSource — plan to start offering coverage in Georgia’s exchange for 2020.

Georgia has proposed partial Medicaid expansion, reinsurance, and the elimination of an exchange platform in the state

Georgia enacted SB106, the Patients First Act, in March 2019. The legislation authorizes the state to submit an 1115 waiver proposal to the federal government that could call for a partial expansion of Medicaid to cover people with income up to 100 percent of the poverty level (the legislation allows the proposal to go up to that amount, but not above it). SB106 also authorizes the state to submit a 1332 waiver to the federal government with a proposal or proposals for improving the state’s individual health insurance market.

In May 2019, the state invited several consulting firms to submit proposals for working with the state to develop 1115 and 1332 waiver proposals, and the state announced in June that Deloitte Consulting had been selected for the project.

Georgia is currently one of 14 states where no action has been taken to expand Medicaid. The state can choose to partially expand Medicaid (up to 100 percent of the poverty level or some level below that). But based on the precedent in Utah, it’s unlikely that the federal government will agree to provide enhanced federal funding (ie, Medicaid expansion level funding) if the state only partially expands coverage. But even a partial Medicaid expansion in Georgia would be a significant improvement over the status quo, as it would close the coverage gap in the state (an estimated 267,000 people are stuck in Georgia’s coverage gap; only Florida and Texas currently have more people in the coverage gap).

The details of Georgia’s proposed 1115 waiver were unveiled in early November. It calls for a partial expansion of Medicaid, and would cover people with income under the poverty level — as long as they are compliant with a work requirement, and in some cases, paying premiums for their coverage. Although full expansion of Medicaid (to cover people with income up to 138 percent of the poverty level) would cover at least 400,000 low-income Georgia residents, the state’s modified expansion proposals is only expected to cover about 52,000 people, even after five years.

Wisconsin and Utah both provide Medicaid coverage for people with income up to the poverty level, but they do not receive the enhanced federal funding for that population, since they haven’t fully expanded Medicaid up to 138 percent of the poverty level (Utah tried to get the enhanced federal funding earlier this year, but CMS rejected their proposal).

Georgia’s proposal does call for a reinsurance program that would cover a portion of high-cost medical claims between $20,000 and $500,000, starting in 2o21. The reinsurance program would target a 10 percent reduction in overall average premiums across the state, but like a model that is successfully being implemented in Colorado, Georgia’s proposal calls for a higher percentage of these claims to be covered by the reinsurance program in areas of the state where premiums are currently the highest, in order to bring down premiums the most in those areas. Reinsurance programs are a tried and true way of bringing down premiums for people who have to pay full-price for their coverage, and they can serve to boost enrollment in the ACA-compliant market by making coverage for affordable for that segment of the population.

But while most states that have thus-far implemented 1332 waivers have used them only for reinsurance programs, Georgia’s proposals goes beyond that. The state also wants to transition away from HealthCare.gov as of 2022 — but instead of establishing a state-run health insurance exchange, Georgia wants to rely on web brokers and insurers to function as enrollment platforms for consumers. The state has dubbed this approach the Georgia Access Model.

Georgia’s proposal calls for the state to receive the same federal funding that would have been used for subsidies via HealthCare.gov, and the money will instead be distributed by the state to help residents cover the cost of qualified health plans (ie, the same sort of plans that are currently available on HealthCare.gov) as well as “non-QHPs” which would have lesser benefits but would still be part of the same risk pool and not medically-underwritten. This goes well beyond what other states have done with 1332 waivers, and it remains to be seen whether the Trump Administration will approve the proposal. The state estimates that total enrollment in health insurance coverage could increase by 30,000 people as of 2022 under the state’s proposal, with more than half of them eligible for financial assistance with their premiums. But experts have expressed concerns about consumers potentially being misled by web brokers and not understanding subpar benefits.

The state is accepting public comments on the 1332 waiver proposal (and the 1115 waiver proposal) through December 3, 2019. The final waiver proposal is expected to be submitted to CMS for review before the end of the year.

Georgia’s exchange has four participating insurers in 2019 — Alliant, Ambetter (Centene), Blue Cross Blue Shield of Georgia, and Kaiser. All four plan to continue to offer exchange plans in 2020, and Oscar Health and CareSource have also filed plans to join the exchange.

Oscar and CareSource both plan to offer coverage in the Atlanta metro area. The filing for CareSource (SERFF filing number CASO-131923864) notes that plans are expected to be offered in parts of Rating Areas 3, 10, and 14. As of mid-August, Oscar’s publicly available filing is a form filing (as opposed to a rate filing), which does not indicate details about specific counties or rating areas.

CareSource currently offers exchange plans in Ohio, Kentucky, West Virginia, and Indiana. They provide Medicaid and CHIP (Peach Care for Kids) coverage in Georgia, but plan to also begin offering exchange plans there as of 2020.

For perspective, here’s a summary of how rates have changed in Georgia’s exchange over the years (more details below for some notable years):

2015: Average increase of 1 percent. Given that southern Georgia had some of the highest premium costs in the nation for 2014, the modest average increase was welcome news for the second year of Obamacare.

2018: Average increase of 54.2 percent (a significant portion of this was due to the Trump administration’s decision to eliminate CSR funding, but premium subsidies are much larger now as a result of that decision).

2019: Average increase of 3.9 percent. Average premiums would likely have dropped in 2019 if not for the elimination of the individual mandate penalty and the expansion of short-term health plans.

Anthem and Georgia Farm Bureau have teamed up to offer Georgia FARM plans starting in the fall of 2019, with coverage effective dates starting in October. The Georgia FARM plan is self-funded as a multiple employer welfare arrangement (MEWA), but will utilize stop-loss coverage from Anthem.

Georgia FARM plans are available to small businesses — including sole proprietors without any additional employees — that are involved in agriculture. All enrolling employees must be members of the Georgia Farm Bureau.

The plans are medically underwritten, in that premiums depend on applicants’ medical history and a small group’s claims history. But pre-existing conditions are covered and the Georgia FARM plans are guaranteed-issue.

Farm Bureau partnerships with insurers exist in several other states; Georgia’s is somewhat unique, although it is similar to the plan that debuted in Ohio in 2016.

Tennessee and Iowa, for example, have Farm Bureau plans that are available to any Farm Bureau member (ie, there is no requirement that the enrollee be actively involved in agriculture) and are designed for healthy people who would otherwise be enrolling in individual market coverage. In both cases, the state has said that the coverage isn’t technically insurance, and thus is not regulated under state insurance laws and does not have to comply with the ACA’s regulations.

In Nebraska, Farm Bureau debuted an association health plan in 2018, with a limited annual open enrollment window, guaranteed-issue coverage, and no medical underwriting.

Georgia FARM’s approach differs from both of these. It does not seem to be using an association health plan model, since those are not currently allowed to enroll sole proprietors (unless they have at least one additional employee enrolling in the plan). But the plan is guaranteed-issue and covers pre-existing conditions, so it also does not appear to be using the Tennessee/Iowa approach of relying on pre-ACA-style medical underwriting.

Anthem has noted that the plan is in compliance with Georgia Department of Insurance requirements, and Georgia’s governor and insurance commissioner have both indicated their support for the FARM plans.

Although medical underwriting allows the FARM plans to provide lower-cost coverage for healthy groups, consumer advocates also worry that the ACA-compliant market could end up with an overall sicker risk pool if sole proprietors and small groups with fairly healthy employees opt to switch to the FARM plans.

Average rates increased by less than 4% for 2019

For 2019, Georgia’s exchange insurers proposed the following average rate changes:

Anthem Blue Cross Blue Shield of Georgia: 0.3 percent decrease (the initial filing had called for a 2.2 percent increase). Anthem returned to a large chunk of northern Georgia in 2019, including the Atlanta metro area (except for Clayton and Rockdale counties), but they left several of the rural counties where they offered coverage in 2018. Anthem offered plans in 85 counties for 2018. According to the Public Use Files that CMS published in late October 2018, Anthem left 41 of those counties at the end of 2018, but joined 31 other counties. So in total, they’re offering plans in 75 counties in 2019, down from 85 in 2018. But their plans are available to more people, due to their re-entry into some of the more populated counties they had exited at the end of 2017. In all 85 counties where Anthem offered plans in 2018, they were the only insurer offering plans. But in 30 of the 31 counties that Anthem joined for 2019, they have competition from at least one other insurer. In the 41 counties where Anthem left, Ambetter is offering coverage in 2019.

Ambetter from Peach State Health Plan (a Centene company): 8.8 percent increase (the initial filing called for a 7.7 percent increase). Ambetter expanded their coverage area to cover the counties where Anthem left the exchange at the end of 2018.

Kaiser: 14.7 percent increase (unchanged from the initial filing)

At ACA Signups, Charles Gaba pegged the average rate increase for 2019 at just under 4 percent. But the average benchmark premium (0n which premium subsidies are based) was only 1 percent higher for 2019 than it was for 2018.

Kaiser’s rate increase was the most significant for 2019, but Kaiser is the only one of the four insurers that didn’t add the cost of cost-sharing reductions (CSR) to their premiums for 2018. Their rate filing for 2019 noted that a significant portion of their rate increase was due to the fact that they are adding the cost of CSR to their on-exchange silver plans, starting in 2019.

For 2019, as was the case for 2018, Georgia’s insurance commissioner did not instruct insurers on how to add the cost of cost-sharing reductions (CSR) to premiums. In 2018, the other three insurers took varying approaches to address the fact that the federal government was no longer reimbursing insurers for the cost of CSR. Alliant added the cost to on-exchange silver plans, Anthem added the cost to all silver plans, and Ambetter spread the added cost across all of their ACA-compliant plans at all metal levels.

Anthem’s rate filing didn’t indicate how they’ve handled the cost of CSR for 2019, but they confirmed by phone that they have added the cost of CSR to all silver plans. A 40-year-old in Baldwin County who earns $20,000 can get a bronze plan from Anthem in 2019 for 52 cents per month after the premium subsidy is applied; free or ultra-low-cost bronze plans become available when the cost of CSR is added to silver plans, making the premium subsidies (which are based on the cost of silver plans) disproportionately large.

While the CSR approach varied significantly across Georgia’s four insurers for 2018, it’s much more uniform for 2019:

Kaiser: Adding the cost of CSR to on-exchange silver plans.

Alliant: Adding the cost of CSR to on-exchange silver plans.

Ambetter: Adding the cost of CSR to on- and off-exchange silver plans.

Anthem: Adding the cost of CSR to all silver plans. Anthem does not sell any silver plans off-exchange-only. So while their silver plans are available both on- and off-exchange, the plans are identical and the cost of CSR has been added uniformly to the silver plans.

Sometimes the easiest way to understand the annual changes in premiums and plan options is to consider real-life examples. Let’s consider two counties in Georgia: Gordon, and Hancock. We’re going to look at example prices for a 45-year-old earning $35,000 (we’ll keep the person the same age in both 2018 and 2019, to compare apples to apples and avoid the inevitable premium increase that happens every time we get another year older). So all of the numbers in this example are specific to a 45-year-old who earns $35,000… if an applicant earns more or less than that, or if they’re older or younger than 45, the numbers will be different.

In Gordon County, Ambetter and Alliant are offering plans in 2019, whereas Alliant was the only exchange insurer in 2018.

The subsidy amount in 2018 was $499/month.

There were six plans available in 2018. After the subsidy was applied, their premiums ranged from $56/month to $315/month.

The benchmark plan (Alliant SoloCare Silver PPO 40010) was about $769/month before the subsidy, and $271/month after the subsidy.

The subsidy is much smaller in 2019, at just $141/month.

There are 22 plans available for 2019. After the subsidy is applied, they range in price from $218/month to $630/month.

The benchmark plan in 2019 (Ambetter Balanced Care 4) is about $419/month before the subsidy, and $277/month after the subsidy.

ALL of the Ambetter plans available in 2019 are less expensive than any of the Alliant plans. There are eight Alliant plans for sale in 2019, and they’re the eight most expensive options out of the 22 available plans.

In Hancock County, only Blue Cross Blue Shield is offering plans as was the case in 2018.

The subsidy amount in 2018 was $373/month.

There were 13 plans available in 2018. After the subsidy was applied, their premiums ranged from $160/month to $726/month.

The benchmark plan (BCBS’s Pathway X HMO 5300) was about $644/month before the subsidy, and $271/month after the subsidy.

The subsidy amount in 2019 is $479/month.

There are eight plans available in 2019, ranging in price from $0/month to $501/month. Three of the plans have $0 premiums, and one is just 77 cents/month.

The benchmark plan (BCBS’s Pathway X HMO 2100 Online Plus) is $756/month before the subsidy, and $277/month after the subsidy.

These data include several key takeaway points:

The after-subsidy price of the benchmark plan is the same for enrollees with equal incomes, regardless of where they live (and regardless of how old they are; a 60-year-old in Gordon County who earns $35,000 in 2019 will get a subsidy of $509/month, but his after-subsidy cost for the benchmark plan will be the same $277/month that our 45-year-old enrollees would pay).

When an insurer is the only one participating in the exchange in a given area, they can design their plan offerings so that the second-lowest-cost silver plan (ie, the benchmark plan, on which subsidies are based) is priced much higher than the lowest-cost silver plan, the bronze plans, and even, in some cases, gold plans (as described above, this is a more recent phenomenon, triggered by the Trump Administration’s decision to eliminate funding for cost-sharing reductions, and the workaround that states and insurers implemented that involves adding the cost of CSR to silver plan rates). This is the case in Hancock County in 2019, and it’s why there are several free or very low-cost options available to some subsidized enrollees. Anthem has adjusted their plan offerings so that their second-lowest-cost plan is a much more expensive option (it has a $2,100 deductible, instead of the $5,300 deductible policy that was the second-lowest-cost plan in 2018). So although Anthem’s average premiums decreased slightly for 2019, they picked a higher-priced plan and made it the second-lowest-cost silver plan, which has resulted in larger subsidies for everyone in that area. This strategy doesn’t work as well in areas with multiple insurers, though, as they don’t know which insurer will have the benchmark plan until the rates are finalized.

When an area gains a new insurer, enrollees will find that their premium subsidy drops sharply if the new insurer undercuts the existing market and offers lower-cost plans, including a new lower-cost benchmark plan (Phoenix, Arizona is another example of this). And if the new insurer doesn’t have a wide spread between their lowest-cost plans and the benchmark plan, people will end up paying more, after the subsidy, for the lowest-cost plans (but if they already had the benchmark plan and they switch to the new benchmark plan, their premiums will remain mostly unchanged, as long as their income doesn’t change). That’s what’s happened in Gordon County for 2019, with Ambetter’s entry into the market. Ambetter’s plans are less expensive than Alliant’s but they don’t have as much of a price difference between their lowest-cost plan and the second-lowest-cost silver plan they offer (which is the new benchmark plan, since Alliant’s silver plans are much more expensive). That’s why our example person could get a plan in Gordon County for $56/month in 2018, but has to pay at least $218/month in 2019.

But the entry of a new, lower-cost insurer is beneficial to those who don’t get premium subsidies. If our 45-year-old applicant in Gordon County earns $60,000 instead of $35,000, he’ll have to pay full price. In 2018, the full price options ranged from $555/month to $813/month. But in 2019, they range from $359/month to $771/month. So this particular applicant will save nearly $200/month if he switches from the lowest-cost 2018 option to the lowest-cost 2019 option.

2018 rate increase would have been 31.5% if CSR funding had continued. But instead, insurers proposed increases in excess of 50% to cover the cost of CSR.

In late September 2017, Commissioner Hudgens announced that the state had completed its review of the proposed 2018 rates and submitted them to CMS for final approval. For each insurer, there were two average proposed premium increases. The smaller one was based on the assumption that cost-sharing reduction (CSR) funding would continue in 2018, while the larger one was based on the assumption that it wouldn’t. At that point, Congress had not appropriated funding for CSR, but the Trump Administration had had also made no official decision on the matter.

Two weeks later, the Trump Administration announced that funding for CSR would end immediately. Fortunately, most states (including Georgia) had already instructed their insurers to either base 2018 premiums on the assumption that CSR funding would end, or to have backup rates ready to go.

Georgia’s Insurance Commissioner sent the following average rate increases to CMS for approval (before it was clear that CSR funding would not continue):

Alliant: 31 percent if CSR funding continued; 53 percent if it didn’t

Ambetter from Peach State Health Plan (a Centene company): 23.8 percent if CSR funding continued; 51 percent if it didn’t (Ambetter expanded their coverage area from 24 counties in 2017 to 44 counties in 2018). Ambetter had 133,943 members on ACA-compliant plans in 2017.

At that point, Charles Gaba of ACA Signups calculated a weighted average rate increase of 31.5 percent if CSR funding continued, and 54.2 percent if it didn’t. Gaba also pointed out that Hudgens has been blatant in his desire to obstruct the ACA, saying in 2013: “Let me tell you what we’re doing (about ObamaCare): Everything in our power to be an obstructionist.”

The Kaiser Family Foundation estimated in early 2017 that if cost-sharing subsidies weren’t funded for 2018, silver plan premiums nationwide would have to increase by 19 percent to make up for the lack of federal funding. But in Georgia, the impact was projected to be more significant, with a 23 percent average increase, in addition to the regular rate increases driven by other factors. That’s just about exactly what we saw in the filings, with a difference of 22.7 percentage points between the two sets of rates.

Ultimately, insurers had to decide which set of rates to use before it was clear that CSR funding would end. According to the Atlanta Journal-Constitution, three of the carriers — Alliana, Ambetter, and Anthem — opted to finalize the higher rates that were based on the assumption that CSR funding would end, while Kaiser opted to finalize the lower rate increase.

Kaiser: 30.8 percent (rates were based on the assumption that CSR funding would continue, so the cost of CSR was not added to premiums)

In late October, Avalere Health published a comparison of average premium changes from 2017 to 2018 in each state, and Georgia had among the largest increases. Avalere’s analysis found that the average silver plan in Georgia (before any subsidies are applied) was 48 percent more expensive in 2018, the average bronze plan was 33 percent more expensive, and the average gold plan was 44 percent more expensive. For perspective, the national averages were 34 percent, 18 percent, and 16 percent, respectively.

Enrollment in Georgia’s exchange

As is the case in most states that use HealthCare.gov, enrollment peaked in Georgia’s exchange in 2016, and has been declining since then. The decrease in enrollment has been caused by several variables, including higher premiums for people who don’t get premium subsidies. But GOP sabotage of the ACA (which is part of the reason for the rate increases) also has a lot to do with it: There’s no longer a penalty for being uninsured after the end of 2018, and the Trump Administration again reduced funding for outreach and enrollment assistance in the weeks leading up to open enrollment, after doing the same thing in 2017. In addition, the Administration has expanded access to short-term plans and association health plans, allowing them to serve as alternatives to ACA-compliant coverage for healthy applicants.

Here’s a summary of how enrollment has changed in Georgia over the years (all numbers are based on total enrollment at the end of open enrollment; effectuated enrollment is always lower, as some enrollees don’t pay their premiums or cancel their plans early in the year):

Insurer participation in Georgia’s exchange

Georgia consumers shopping for health insurance on the marketplace had nearly double the number of insurers to choose from in 2015 as they did in 2014. In addition, three companies — as opposed to one in 2014 —offered policies statewide.

Nine insurers offered plans in the Georgia health insurance marketplace for 2015, including four that were new to the exchange for 2015. The returning companies from 2014 were: Alliant Health Plans, Blue Cross Blue Shield of Georgia, Humana, Kaiser Permanente, and Peach State Health Plans (Ambetter). The new entrants to the marketplace for 2015 were Cigna, Coventry/Aetna, UnitedHealthcare, and Time Insurance.

Time/Assurant only offered exchange plans for one year, as they exited the health insurance market nationwide at the end of 2015. But Harken Health Insurance joined the Georgia exchange for 2016, so there were still nine carriers offering plans in 2016.

However, all of those newcomers had left the exchange by the end of 2016:

UnitedHealthcare: In April 2016, a Georgia state insurance office spokesperson confirmed that UnitedHealthcare would exit the exchange in Georgia at the end of 2016. This was not unexpected, given that United had hinted at the possibility of eventually pulling out of the exchanges in the fall of 2015, and had cut broker commissions in most states for 2016 in an effort to reduce sales. UnitedHealthcare’s market share in the Georgia exchange was relatively small in 2015, with 825 enrollees in plans through UnitedHealthcare Life Insurance, and 9,933 in plans from UnitedHealthcare of Georgia.

Aetna: Aetna offered plans in 67 of Georgia’s 159 counties in 2016, but they exited the exchange at the end of 2016. They had somewhere between 70,000 and 90,000 on-exchange enrollees in Georgia.

Harken Health: Harken Health joined the exchange in the Atlanta area for 2016, but exited at the end of the year and did not offer exchange plans in Georgia (or in Illinois, where they offered exchange plans in the Chicago area in 2016) in 2017. Harken continued to offer off-exchange plans in the Atlanta area, but only until mid-2017, when the insurer exited the market altogether.

So Georgia had five insurers participating in the exchange in 2017. As was the case in most states, however, insurer participation in localized: most of southern Georgia had just one insurer (Blue Cross Blue Shield of Georgia, an Anthem company) offering plans in the exchange in 2017, while most of the northern part of the state had two or more participating insurers.

Humana exited Georgia’s market at the end of 2017, and is no longer offering individual health insurance anywhere in the nation. In Georgia’s exchange, Humana plans were only available in 2017 in Atlanta, Columbus, Macon, and Savannah. Humana had the largest percentage rate increase in the Georgia exchange for 2017, and their total exchange enrollment across 11 states was only about 150,000 people in 2017. So their exit at the end of 2017 was not unexpected, and did not have a dramatic impact.

In 2018, although there are four insurers offering plans in the Georgia exchange, only 14 of the state’s 159 counties have two insurers participating in the exchange; the rest of the counties have a single insurer offering coverage.

Blue Cross Blue Shield of Georgia (an Anthem company) was the only insurer offering coverage in 96 of Georgia’s 159 counties in 2017, and their continued participation in exchanges across the country was uncertain in the spring and summer of 2017. In May 2017, Blue Cross Blue Shield of Georgia filed plans to once again offer coverage statewide in 2018, but they indicated in June that they were planning to withdraw their filing and not offer 2018 coverage.

By early August, however, Anthem had reached an agreement with Georgia Insurance Commissioner Ralph Hudgens, in which they agreed to continue to offer coverage in 85 Georgia counties. The 85 counties were mostly rural areas that would have had no other insurer offering coverage in the exchange if Anthem had exited altogether. The Georgia Office of the Insurance Commissioner confirmed that those 85 counties were specifically selected in the agreement between Hudgens and Anthem due to the fact that they would have been left with no insurer in 2018 if Anthem had proceeded with their initial plan to exit the Georgia exchange altogether.

Alliant also remained in the exchange, with plans available in northern Georgia, and the other two Georgia insurance carriers — Kaiser and Ambetter — also continued to offer plans in the exchange, so Humana was the only insurer that left the exchange at the end of 2017.

A full list of the counties where each insurer is offering plans in the Georgia exchange is available here. The counties shaded in yellow in the Ambetter column were new for Ambetter in 2018 (Ambetter’s 2017 service area included the 24 counties that aren’t shaded in yellow on the 2018 coverage area list). There were no counties without an insurer in the exchange in 2018, which would not have been the case if Anthem hadn’t agreed to remain in the exchange in 85 Georgia counties.

Earlier in 2017, Anthem had indicated that they were considering exiting a large number of the areas/states across the country where they currently offer coverage — a scenario that was obviously of great concern in a state like Georgia where there are no other options in much of the state. By late April, Anthem had said that they were planning to participate in the exchanges in 2018, assuming the Trump Administration continued to fund cost-sharing reductions (CSR). But by August, Anthem had announced that they would exit the exchanges in Indiana, Wisconsin, Ohio, and Nevada, and would scale back their participation in Georgia and California.

Legislation to protect broker commissions, but only during open enrollment

Georgia lawmakers have passed legislation to require broker commissions in some cases, although the minimum amount that brokers must be paid has not been specified. Similar, but more detailed, legislation had failed in 2016.

HB838 passed the Georgia house in February 2016 by a huge margin (144 – 17), and was sent to the Senate, where it was ultimately tabled in late March. If it had been enacted into law, the legislation would have required health insurance carriers to pay broker commissions (at least 5 percent for group plans and at least 4 percent for individual plans) when brokers are used to enroll people in health plans.

But in 2018, another bill, HB64, passed both chambers of the Georgia legislature by wide margins, and was signed into law by Governor Deal. The 2018 bill was a compromise — it only requires broker commissions for plans sold during open enrollment (not during special enrollment periods), and it does not set a specific level for commissions, leaving that up to the insurance commissioner and health insurers. And Rep. John Meadows, a licensed insurance agent who co-sponsored HB838, did not co-sponsor HB64. His sponsorship on HB838 had raised concerns about a potential conflict of interest in 2016.

The bills were in response to several national carriers cutting back or eliminating broker commissions, particularly for plans sold during special enrollment periods in 2016. Humana reduced broker commissions to three percent for bronze and catastrophic plans as of March 2, 2016, and eliminated commissions entirely for all other metal levels (Humana is no longer offering ACA-compliant plans anywhere in the country, and left Georgia’s market at the end of 2017). Anthem eliminated commissions in Georgia —and nine other states — for 2016 plans with effective dates of April 1, 2016 or later (ie, purchased outside of open enrollment), and UnitedHealthcare eliminated commissions as of January 1, 2016.

Carriers have balked at what they see as lax enforcement of special enrollment period eligibility for plans sold through Healthcare.gov, and the commission reductions have generally been seen as an effort by carriers to reduce enrollment outside of open enrollment. To address carrier concerns, CMS announced in February 2016 that Healthcare.gov would begin requiring documented proof of a qualifying event in order to grant special enrollment periods (SEPs). HealthCare.gov also announced a pilot program beginning in 2017 to further step-up eligibility verification for SEPs, which was ultimately expanded to cover all SEP enrollments.

Background on the marketplace in Georgia

Georgia opted to use the federal health insurance marketplace, HealthCare.gov. State government officials such as former Gov. Nathan Deal and former Insurance Commissioner Ralph Hudgens vocally opposed the Affordable Care Act.

Hudgens implemented a requirement that navigators, who help consumers use the marketplace, pass the test that insurance agents are required to take. That requirement was much more stringent than required by the health care reform law, and Hudgens openly stated it was intended as obstructionism. At the end of its 2014 session, the Georgia Assembly passed a bill that prohibits establishing a state-run marketplace, disallows the use of taxpayer money for navigator programs, and forbids government employees from advocating for Medicaid expansion.

Georgia’s director of Enroll America, Dante McKay, said that lack of access to navigators hurt enrollment in rural Georgia counties in 2014. McKay also said the amount of federal funding Georgia received for navigators was among the lowest of all the states on a per uninsured person basis in 2013 — and the amount decreased in 2014.

Georgia has also thus far refused to accept federal funding to expand its Medicaid program under the ACA. Gov, leaving up to 267,000 low-income residents in a coverage gap — unable to qualify for either Medicaid or subsidies through the marketplace.